Patient dependency in emergency care: do we have the nurses we need?

To use the previously validated Jones Dependency Tool to establish current patterns in the dependency of patients attending the Emergency Department of an inner city teaching hospital, thereby informing present and future decisions regarding nursing numbers and grade mix.

Nursing salaries are the largest single expenditure in the National Health Service, but the number and grade of nursing staff are often determined by historical or arbitrary measures. Staffing calculations based only on the number of patients fail to take account of dependency and, hence, the actual nursing workload.

The Jones Dependency Tool, a validated measure of Emergency Department patient dependency, was used prospectively to collect data on all patients attending an adult Emergency Department over a two-week period. The primary outcome measure was patient dependency assessed on arrival and departure and at four and eight hours if the patient was still in the Emergency Department. Data were analysed using descriptive statistics and chi-squared testing.

Data were collected on 48% of all patient attendances; 10% of patients were in the high- or total-dependency groups on arrival. Patients tended to become less dependent during their Emergency Department stay and analysis of those individuals in whom dependency increased was valuable. The proportion of high and total-dependency patients did not vary by day of the week, but was significantly increased overnight. This emphasizes the weakness of basing staffing levels on patient numbers alone.

Patient dependency is one of the essential determinants of nursing grade mix and with further work and adaptation the Jones Dependency Tool can be used to predict workload, resource use and the optimal staffing levels that will provide safe and effective patient care.

Dependency can be readily and repeatedly assessed and we recommend this approach to other Emergency Departments.